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Risk factors fpr placental abruption

HTN
Prior placental abruption
Chronic hypertension
Pregnancy-induced hypertension
Cocaine
EtOH or tobacco use
Vascular disease sucha s DM and SLE

Most significant risk factor for placental abruption

HTN
Sustained >160/110 treat pharmacologically

Uncontrolled maternal HTN

FUGR
Oligohydramnios
Abruption

Risk factors for placental previa

Prior c-delivery
Multiparity
Multiple gestation
Advanced maternal age

Uterine atony --> hemorrhage risk factors

Multiple gestation
Polyhydramnios

Night sweats, irregular menses, insomnia in a middle aged woman

Menopause
Hyperthyroidism

Hormone changes during menopause

Decrease in estrogen resulting in decrease in the feedback inhibition ont he hypothalamic-pit axis --> elevation of FSH and LH

Menopause how to diagnose in the absence of lab values

>45 age
12 month history of amenorrhea without other physiologic causes

US reveals solid ovarian tumors, pregnant vs nonpregnant management?

Pregnant - benign luteoma, which usually appears as b/l multinodular solid masses on both ovaries. Replacement of noraml ovarian parenchyma by a solid prolifeartion of luteinzed stromal cells under the influence of HCG... Most common in AA multiparous women in 30s and 40s. Often asymptomatic... but 1/3 develop sx of hirsutism and virilization.... often benign and self limited and requires no treatment.

Nonpregnant --> needs biopsy and aggressive eval, because they are almost always malignant.

Solid ovarian tumors in pregnant

Classic luteoma of pregnancy. Most common in AA multiparous women. Often asymptomatic, but in 1/3 of patients hirsutism and virilization can develop. Benign and self limited, req NO treatment.

Hypogonadotrophic hypogonadism

2/2 low FSH LH concentrations
Can result from strenuous exercise, anorexia nervosa, marijuana use, starvation, stress, depression, and chronic illness.

FSH and LH drop--> estrogen and testosterone drop --> osteoporosis and decreased muscle mass. Patients will often suffer infertility.

Connection between hypogonadotrophic hypogonadism and hypothyroidism

Can be direct result of hypothyroidism, or be the result of a condition that is also causing hypothyroidism (pituitary pathology).

Atypical endometrial hyperplasia cause

Excessive levels of circulating estrogens or estrogen-like compounds.

Risk factors for gout

Male gender
Diuretic use
EtOH
Obesity
Diet rich in purines (organ meats, game, seafood)

NOT at high risk for gout.

Major risk factor for ectopic pregnancy

PID (subsequent episodes increase risk markedly)

Dysfunctional uterine bleeding treatment

High dose estrogen

This is a diagnosis of exclusion!!

Triad of ectopic

Amenorrhea
Abdominal pain
Vaginal bleeding

Most importnat intervention for preventing spread of HIV from mother to child

Zidovudine treatment (NRTI), aka Azidothymidine, to mother throughout pregnancy and labor, as well as to the neonate for first 6 weeks of life...

Decreases rate of transmission by 70%..

Interventions that decrease mother to infant transmission of HIV

Zidovudine treatment of mother and neonate (70% decrease)
Elective cesarean (50%), combine with above.

Premature ovarian failure characterized by

Amenorrhea
Hypoestrogenism
Elevated serum gonadotropin levels in women age <40 years

Amenorrhea of 3 months duration with FSH in menopausal range

Causes of premature ovarian failure

Accelerated follicular atresia
Low initial number of primordial follicles

Most commonly idiopathic, but may also be due to mumps, oophritis, irradiation, chemotherapy... Can also be associated with autoimmune disorders such as Hashimoto thyroiditis, Addison disease, DM-I, pernicious anemia... this supports diagnosis that some cases of idiopathic premature ovarian failure are of autoimmune origin.

Treatment for infertility with PCOS

Clomiphene citrate (SERM)
Metformin (may also be used to promote ovulationin patients, because insulin resistance seenin this condition may contirbute to inability to ovulate normaly)

TWO most common causes of hypopituitarism in teh postpartum period

1. Sheehan syndrome
2. Lymphocytic hypophysitis (less common)

Lymphocytic hypophysitis: present with

HEadaches, visual disturbances, and pituitary failure. Can be difficult to distinguish from pituitary neoplasm

Infiltrative disorders of the pituitary typically present with what

Diabetes insipidus

Sheehan syndrome presentation

In the few months following birth, lethargy, weight gain, fatigue, amenorrhea, dry skin, delayed tendon reflexes........

Aromatase deficiency results in what

Lack of enzymes that converts androgens into estrogens, and thus low estrogens...

In utero, placenta does not make estrogens and thus high level of androgens --> virilization of mother that resolves after delivery... high level of gestational androgens result in virilized XX child with normal internal genetalia but ambiguous external genitalia...

Baby born with clitoromegaly, what is the cause usually

Often seenwhen excessive androgens are present in utero.

Aromatase deificency signs nad sx

Normal internal genitalia
Ambig external genitalia
Clitoral hypertrophy
High FSH/LH w/ low estrogen.

Normal internal genitalia (female) w/ ambiguous external genitalia, low estrogen

Aromatase deficiency

Most common cause of CAH

21 hydroxylase deficiency. Also have salt wasting...

Estrogen is still synthesized.

McCune Albright syndrome triad

Cafe au lait spots
Polyostotic fibrous dysplasia
Autonomous endocrine hyperfunction --> gonadotropin independent precocious puberty (early puberty!!)

Kallman syndrome

Hypogonadotropic hypogonadism w/ anosmia
Delayed puberty but low or absent LH and FSH levels

Galactose-1-phosphate uridyltransferase deficiency

Galactose-1-phosphate accumulation i nliver, brain, kidney --> cirrhosis, mental retardation, and Fanconi syndrome

Deficiency which causes gestational maternal virilization

Aromatase deficiency

Vulvar skin is thin, dry, and white in color

Lichen sclerosus (lichen sclerosus et atrophicus), an autoimmune phenomenon...

Anogenital discomfort with pruritus, dyspareunia, dysuria, and painful defecation..

Long term effects of Lichen sclerosus

Sclerosus and scarring --> obliteration of the labia minora and clitoris and a decrease in the diameter of the introitus.

Vulvar SCC -->occurs more commonly in women w/ LS&A. Punch biopsy of any suspicious lesions should be performed.

Estrogen cream good for what

Menopause-related atrophic vaginitis, which can also be a cause of vaginal pruritus and dyspareunia

Treatment of lichen sclerosus et atrophicus

Considered a premalignancy, so surveillance with reg clinical exams and biopsies

High potency steroids (few conditions for which this is encouraged), because it is a chronic inflammatory condition.

Chlamydia treatment

Doxycycline OR
Azithromycin

Polymicrobial infection such as postpartum endometritis

Ampicillin
Gentamicin

Presence of feto-maternal hemorrhage, what test?

Rosette test.... Treat matenral blood with anti-Rh, then R2R2 cells.

If negative administer anti-D immune globulin as per usual.
If positive, amount of hemrorhage can be evaluated with a Kleihauer-Betke stain or fetal red cell stain using flow cytometry and the dose of Anti-D immune globulin should be adjusted accordingly.

Test for feto-maternal hemorrhage

Rosette test

When should standard dose of Anti-D be administered in an uncomplicated pregnancy

28 weeks, again at delivery. Risk of alloimmunization before 28 weeks is very low.

Amniotic fluid embolism is a well recognized complication of what

Amniocentesis. Presents with sudden respiratory failure, is often accompanied by cardiogenic shock and seizures.

Feared complication of Amniotic Fluid Embolism

DIC

Immediate management of amniotic fluid embolism

Adequate respiratory support. Facemask ventilation, or intubation.

AFE s/sx

Abrupt onset of hypoxia, respiratory failure, cardiogenic shock, and DIC

Symptoms in endometriosis

Usually asymptomatic

When sx: chronic pelvic pain that is worse in premenstrual period, dysmenorrhea and pain with sexual intercourse or defecation. Exam: rectovaginal tenderness or tenderness with mvoement of the uterus due to presence of ecotpic endometrial tissue in the rectovaginal septum and pelvic peritoneum... blah blach blach.

Gold standard for diagnosis of endometriosis

Laparoscopy

Connection between infertility and endometriosis

Up to 30% of females being evaluated for infertility are found to have endometriosis

Mechanisms for infertility in endometriosis

Adhesion formationw/i peritoneum that interferes wtih the normal transfer of oocytes from the ovaries to the fallopian tube
Endometrial factors within uterus that may provide suboptimal environment for implantation
Hormonal stuff that have yet to be determined

Risk factors for endometrial cancer

Advancing age
Use of unopposed estrogen in the past
Prolonged use of tamoxifen
Obesity
Nulliparity
PCOS (Stein-Leventhal)

Risk factors for breast cancer

EArly menarche
Late menopause
Nulliparity

Cowden syndrome?

aka Multiple hamartome syndrome

Increase in hamartomas, and increased risk of certain forms of cancer....

Loss of function mutation in PTEN, a TSG that leads to hyperactivity of mTOR...

Cowden syndrome s/sx

Macrocephaly
Intestinal hamartomatous polyps
Acral keratoses
Dysplasti gangliocytoma of the cerebellum --> Lhermitte-Duclos disease

Cowden syndrome, predilection to what cancers

Breast carcinoma
Follicular carcinoma of the thyroid
Endometrial carcinoma

What increases risk of abruptio placentae

HTN
Cocaine
Smokers
Advanced age
Preeclampsia

Risk for preterm labor

Prior preterm labor
Multiple gestation
Premature rupture of membranes
Exposure to diethylstilbestrol

Dysfunctional uterine bleeding, how to diagnose

Heavy vaginal bleeding that occurs in the absence of structural or organic disease... normal pelvic exam + negative pregnancy test --> DUB.

Steps in the w/u for DUB

Endometrial biopsy, to r/o endometrail hyperplasia or carcinoma....

Esp in >35 yo, obese, chronically hypertensive, or diabetic...

Risk factors for endometrial hyperplasia or carcinoma

>35 yo
Obese
Chronically hypertensive
Diabetic

Treatment for DUB

Screen those with risk factors for endometrial business

Cyclic progestins... if that fails, endometrial ablation or hysterectomy.

Corticosteroid treatment for what GA

No benefit after 34 weeks, use is limited to 24-34 weeks. Additionally corticosteroids require 24-48 hours to have maximum benefit on fetal lung maturity

Atrophic vaginitis s/sx

Vaginal dryness
Pruritus
Dyspareunia
Dysuria!!
Urinary frequency

Pelvic exam in atrophic vaginitis

Pale, dry,and smooth vaginal epithelium
Scarce pubic hair
Loss of labial fat pad....

This results from decrased estrogenlevelss.

ATrophic vaginitis may be confused by symptoms for what

UTI (dysuria and urinary frequency)

Treatment for atrophic vaginitis

Mild - lotions, moisturizers

Mod-severe - low dose vaginal estrogen therapy

How to assess infertility due to aging

Early follicular phase FSH level
Clomiphene challenge test
Inhibin-B level

Signs of premature ovarian failure

<40
Amenorrhea, can also be caused by autoimmune conditions, heritable factors, exogenous factors such as radiation exposure, and as an idiopathic condition.

Most common cause of decreased fertility in fourth decade

AGe-related decreased ovarian reserve

PCOS diagnosis

Clinical: hirsutism, acne, or male pattern baldness or androgenic alopecia and/or biochemical high serum androgen concentrations
Amenorrhea or oligomenorrhea
Pelvic U/S with cystic ovaries, small cysts are noted around the ovaries in a classic "string of pearls" appearance.

Pelvic U/S with cystic ovaries

Small cysts are noted around the ovaries in a classic "string of pearls" appearance

Obesity and PCOS

Just 50%

PCOS risks for what

Infertility
Insulin resistance
DM-II
Cardiovascular disease
Endometrial cancer
Dyslipidemia

PCOS patients should be screened for what

Insulin insensitivity
DM-II

Do an OGTT

CA-125 good for what

Ovarian cancer (used to monitor therapy)

Causes of severe vomiting during pregnancy

Hyperemesis gravidarum
Gestational trophoblastic disease (hydatidiform mole and choriocarcinoma)

Clinical course of hyperemesis gravidarum

Vomiting begins in weeks 4-10
GEnerally resolfves by mid pregnancy

Triad for a hydatidiform mole

Enlarged uterus
Hyperemesis
Markedly elevated HCG (>100,000)

Good test in the work-up for vomiting in pregnancy besides basics

HCG --> Hydatidiform mole.

Hyperemesis gravidarum diagnostic factors

Persistence of vomiting
Loss of >= 5% prepregnancy weight
Ketonuria

Diff diagnosis for hyperemesis gravidarum

Pyelonephritis
Gestational trophoblastic disease
Gastroenteritis
Hepatobiliary disease

Pyelo
Gestational trophoblastic disease
Gastroenteritis
Hepatobiliary disease

Suspected PCOS in whom

Menstrual irregularities +
Evidence of hyperandrogenism

Two things needed for PCOS

Menstrual irregularities
Evidence of hyperandrogenism

PCOS risk for what

Endometrial cancer

Adequate amount of active estrogens. Androgens will be converted into estrogens in the peripheral tissues. Deficient in progesterone secretion, and thus constant and unbalanced mitrogenic stimulation of the endometrium by estrogens leading to endometrial hyperplasia, intermittent breakthrough bleeding, and dysfunctional uterine bleednig.

PID criteria diagnosis

Fever>38 C
Leukocytosis
Elevated ESR
Purulent cervical discharge
Adnexal tenderness
Cervical motion tenderness
Lower abdominal tenderness

PID causes

N. gonorrhea
C. trachomatis
Genital mycoplasmas

Regimens for PID, hospitalized

Cefoxitin/Doxycycline
Cefotetan/Doxycycline
Clindamycin/Gentamicin

Regimens for PID, outpatient

Cefoxitin + Probenecid + Doxy
Ceftriaxone + Doxycycline

Maternal opioid abuse

Withdrawal symptoms in the infants following birth --> irritability, tremors, vomiting, diarrhea, and salivation. Long-term CNS deficits in these infants and an increased risk of SIDS

GBS in infants

Pneumonia
Meningitis
Sepsis

w/i first seven days of life

Uncontrolled maternal DM

Fetal macrosomia
Birth injuries
Congenital malformations
Hypoglycemia
Polycythemia
Respiratory distress
Cardiomyopathy among other possible findings

Fetal alcohol syndrome, typical findings

Growth restriction
Midfacial hypoplasia
Smooth philtrum
Short palpebral fissures
Thin upper lip
CNS abnormalities

Emergency contraception

Levonorgestrel

Effective up to 120 hours post intercourse, but effectiveness is greater the earlier the medication is administered.

Effectiveness of the plan B

7 out of 8 women who would have otherwise become pregnant from intercourse.

Depo provera, what is this

IM medroxyprogesterone.

2nd trimester abortifacient

Prostaglandin E2 suppositories

Diff dx for hyperemesis gravidarum

Pyelo
Gestational trophoblastic disease
Gastroenteritis
Hepatobiliary disease

PCOS deficient in what

Progesterone secretion, thus they have constant and unbalanced mitogenic stimulation of the endometrium by estrogens leading to endometrial hyperplasia

Fetal alcohol syndrome s/sx

IUGR
Microcephaly
Facial dysmorphology: midfacial hypoplasia, micrognathia, flattened (smooth) philtrum, microphthalmia, short palpebral fissures, thin upper lip
CNS damage: irritability, ADHD, learning disabilities, frank mental retardation

When does GBS typically occur

W/i first seven days of life. But then there's also late onset...

Symptoms of withdrawal in an infant

Irritability
Tremors
Vomiting
Diarrhea
Salivation

Long term CNS deficits wtih increased risk of SIDS

Uncontrolled diabetes maternal-fetal effects

Macroscomia
Birth injuries
Congenital malformations
Hypoglycemia
Polycythemia
Respiratory distress
Cardiomyopathy

Window for emergency contraception

120 hours

Depoprovera is what

Medroxyprogesterone q3 months

Breech presentations <37 weeks, usual fates?

Self-correction by the 37th week of gestation, thus no external version is recommended before that time.

Contraindications to external version for breech positioning

Placental abnormalities
Fetopelvic disproportion
Hyperextended fetal head

When should screening for GDM take place

High risk: first prenatal visit
Others: 24-28 weeks

One hour 50g OGTT used as initial screening. If <140, GDM ruled out... If >140, three hour 100g OGTT is then performed
Fast >95
One hour serum glucose >180
Two hour serum glucose >155
Three hour serum glucose >140

Androgen insensitivity syndrome

Testicular feminization --> defect or absence of androgen receptors resulting in androgen resistance of all peripheral tissues... Female phenotype with a 46XY. Still normla testes that are typically found in the abdomen or inguinal canal, and patients are prone to inguinal hernias....

MIF produced by testes, and prohibits formation of the uterus, fallopian tubes, and upper portion of vagina...

Breasts develop because of peripheral conversion of testosterone to estrogen, whereas axillary and puibic hair does not develop since it is dependent on testosterone.

Treatment: Testicular resection, creation of a neovagina.

Mullerian agenesis

Primary amenorrhea and nondeveloped internal reproductive organs,but normla XX karyotype with normal testosterone.... Normal axillary and pubic hair development since they respond appropriately to testosterone.

Sx of androgen resistance

Amenorrhea
Normally developed breasts
Absent pubic and axillary hair
Absent internal organs
46XY karyotype

Who gets granulosa cell tumors

Bimodal age distribution.
Young - Precocious puberty
Old - Postmenopausal bleeding, uterine myohyperplasia, absence of vaginal atrophy

S/Sx of dysgerminoma

Neutral hormone-wise, may arise in younger women or children, average incidence 20.
Occasionally they undergo torsion

S/Sx of sertoli-leydig cells

Androgen producing, causes defeminization followed by masculinization. May have altered body contour, flattening of breasts, scanty/irregular menstruation, ultimately ending in amenorrhea....
Hirsutism, coarsening of the features, enlargement of the clitoris.

Most common cystic ovarian neoplasms

Serous cystadenomas - 30% of all ovarian tumors. 25% of all these are malignant, and about half of the cases are bilateral. Usually do not produce estrogen or androgens...

Ovarian mass and abdominal pain are presenting features.

Chorionic villus sampling can be done when

10-12 weeks gestation....

Indicated in women over 35 yo with an abnormal US.

Slightly higher risk than amniocentesis

When is amniocentesis done

16-18th weeks gestation

There is also early amniocentesis<15weeks, reserved for those who cannot have chorionic villus sampling.

What is codocentesis

aka Percutaneous Umbilical Blood Sampling.... used for rapid karyotype analysis or when fetal blood dyscrasias such as fetal anemia and Rhesus isoimmunization are suspected.... Also for when mosaicism is suspected by CVS or amnio to further assess the fetal karyotype.

MSAFP good for screening for what

Neural tube and abdominal wall defects
Chromosomal anomalies when serum levels of estriol and bHCG are also assessed....

First trimester way to detect fetal chromosomal abnormalities

Chorionic villus sampling.

Risks of CVS

Fetal death
Limb reduction defects

Limb reduction defects are greatest when procedure is done before nine to ten weeks gestational age...

CVS done when

10-12 weeks gestation

Diethylstilbestrol exposure in utero predisposes to what in female offspring

Cell cell adenocarcinoma of vagina and cervix
Cervical abnormalities (hypoplasia)
Uterine malformations (T-shaped, small uterine cavity)
Vaginal adenosis and vaginal septae

Many also have difficulty conceiving and maintaining pregnancy.

DES what is this

Diethylstilbestrol, used between 1947-1971 for the treatment of threatened abortion... Female offspring of treated women have higher risk of clear cell adenocarcinoma of the vagina and cervix among other thigns

Diethylstilbestrol predisposes male offspring to what

Cryptorchidism
Microphallus
Hypospadias
Testicular hypoplasia

Risk factor for VAGINAL scc?

HPV

Risk factors for endometrial cancer

Chronic unopposed estrogen use (PCOS??)
Obesity
Nulliparity
Late menopause
Hypertension
Diabetes mellitus
Chronic TAMOXIFEN use

Risk factors for ovarian cancer

FHx
Nulliparity
Lack of prior oral contraceptive use

PE findigns in adenomyosis

Enlarged but generally symmetrical uterus

Differential diagnoses for adenomyosis

Leiomyoma
Endometrial carcinoma

All can present with dysmenorrhea, menorrahgia and a large sized uterus

>35? Endometrial curettage to r/o endometrial carcinoma.

Endometritis presentation

Fever
Enlarged and tender uterus
Foul smelling vaginal discharge

Usually occurs after a septic abortion or in the postpartum period (puerperal fever)

Who gets adenomyosis typically?

Multiparous women >40 yo. Typically presents with dysmenorrhea and menorrhagia. PE reveals enlarged and generally symmetrical uterus...

DDx; fibroids, but this is irregularly shaped uterus.

Indications for GBS prophylaxis when GBS status is unknown

Delivery<37 weeks
Duration of membrane rupture >=18 weeks
GBS bacteriuria in any concentration during current pregnancy
PHx of previous delivery of infant with GBS sepsis

GBS prophylaxis

PCN during labor
Alternatives: ampicilling, cefazolin, clindamycin, or vancomycin...

Tocolysis in the setting of PPROM

Short term, so that glucocorticoids can be given to promote fetal lung maturity.. usually <32 weeks gestation, often 32-34, but never >=35 weeks

When is injection of dye into the uterus helpful

Early early PPROM, when ROM is difficult to confirm. PPROM early on may commit pregnant woman to long term bedrest.

Antenatal corticosteroids, when typically

<32 weeks gestation.
Prevents neonatal RDS, necrotizing enterocolitis, neonatal intraventricular hemorrhage, and neonatal death....

Beyond 32 weeks, hard to tell... though many centers continue to administer bethamethasone at gestational ages b/w 32-34 weeks for patients with PPROM. Glucocorticoids are typically not given after 34 weeks.

Most common type of precocious puberty

Idiopathic central precocious puberty, resulting from premature activity of H-P-G axis... They have pubertal levels of basal LH that increase with GnRH stimulation, whereas patients with peripehral source have no stimulation+ test....

Precocious puberty of central origin, next test

Brain imaging to r/o CNS lesion

Treatment for precocious puberty of central origin

GnRH agonist

What is Cyproterone acetate

Steroid-based compound with antiandrogenic and antigonadotropic effects, used in Europe second line for hirsutism.

Danazol

Progestin-like med useful in the treatment of endometriosis and fibrocystic breast disease.

Medroxyprogesterone acetate

Inhibits secretion of gonadotropins, used for contraception and abnormal uterine bleeding.

Treatment for GDM

Diabetic diet
SC Insulin (category B agent, does not cross placenta)

GDM pregnancy risks

Miscarriage
Macrosomia
Congenital malformations
Preterm birth
Pyelo
Preeclampsia
Meconium aspiration,
Stillbirth

Ideal range of FBG

75-90

GDM effectson the fetus

Macrosomia
Hypocalcemia
Hypoglycemia
Hyperviscosity due to polycythemia
Respiratory difficulties
Cardiomyopathy
CHF

Why polycythemia in infant born to diabetic mother?

Fetal hypoxia which occurs in face of increased basal metabolic rate induced by hyperglycemia. Increased EPO production by the fetus increases RBC mass and oxygen carrying capacity of the blood.

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